II. Evaluation: Tobacco, Alcohol, Caffeine and Substance Use

  1. Tobacco Cessation
    1. Most important single preventable U.S. risk:
      1. Low birth weight
      2. Perinatal mortality
      3. Ectopic Pregnancy
      4. Miscarriage
      5. Placental Abruption
      6. Orofacial Clefts
    2. Epidemiology
      1. Women (especially ages 25-44) who smoke: 25%
      2. Women who stop smoking in pregnancy: 21%
      3. Women who resume smoking within 1 year: 70%
    3. References
      1. (2020) Obstet Gynecol 135(5):e221-9 +PMID: 32332417 [PubMed]
  2. Alcohol abstinence
  3. Caffeine reduction to under 3 cups per day
  4. Avoid Recreational Drug Use
    1. Marijuana
    2. Cocaine
    3. Heroin

III. Evaluation: Infectious Disease

  1. Evaluate risk and screen as indicated for Sexually Transmitted Diseases and other infections
    1. HIV Infection
      1. Discuss universal screening and risk of vertical transmission
    2. Syphilis
      1. Screen high risk women
    3. Hepatitis B
      1. Screen if risk, especially if not immunized
      2. Discuss risk of vertical transmission in Chronic Hepatitis B Carrier
    4. Gonorrhea
      1. Screen high risk women
    5. Chlamydia
      1. Screen all women under age 25 years and those at increased risk
    6. Herpes Simplex Virus infection
      1. Discuss risk of vertical transmission and recognition of genital outbreaks during pregnancy
    7. Tuberculosis
      1. Screen high-risk women
      2. Treat active and Latent Tuberculosis prior to pregnancy
  2. Immunizations (avoid conception within 4 weeks unless otherwise noted)
    1. RubellaVaccine
      1. Indicated if negative for Rubella IgG and not pregnant
      2. Avoid pregnancy for 3 months after RubellaVaccine (Live Vaccine)
      3. If pregnant and not immune, schedule RubellaVaccine for postpartum
    2. Varicella Vaccine
      1. Indicated if negative for Varicella IgG and not pregnant
      2. Avoid pregnancy for 1 month after Varicella Vaccine
      3. If pregnant and not immune, schedule Varicella Vaccine for postpartum
    3. Tdap Vaccine
      1. Vaccinate all pregnant women at 27-30 weeks gestation with each pregnancy
      2. Provides passive Immunity to the infant against Pertussis
    4. Pneumococcal Vaccine
      1. Indicated if high risk for pneumococcus (e.g. Asplenic)
    5. Hepatitis B Vaccine
      1. Vaccinate all women prior to pregnancy if not already vaccinated
    6. Influenza Vaccine
      1. Vaccinate all women pregnant during Influenza season (as well as those with other indications)
    7. Covid Vaccine
      1. Covid 19 infection doubles the risk of preeclampsi
  3. Avoid Toxin or Infection Exposures
    1. See Teratogen Exposure for occupational, household product risk (Heavy Metals, solvents, Pesticides)
    2. Toxoplasmosis (cat litter, garden soil, raw meat)
    3. Cytomegalovirus, Parvovirus, Chicken Pox (child care)
    4. Listeria (cold cuts, undercooked or raw meats)
    5. Condoms or abstinence if partner has STD

IV. Evaluation: Miscellaneous Concerns

  1. Screen for Domestic Violence (Intimate Partner Violence)
  2. Screen for Mood Disorder (Major Depression and Anxiety Disorder)
  3. Avoid overheating (e.g. hot tubs, saunas) due to increased risk of Neural Tube Defects and Miscarriages
  4. Recommend Exercise in Pregnancy
  5. Wear Seat Belts (three point Seat Belt)
  6. Work toward ideal body before pregnancy
    1. See Pregnancy Risk Assessment regarding Obesity and underweight associated pregnancy risks

V. Management: Diet and Supplements

  1. See Nutrition in Pregnancy (includes Teratogenic foods)
  2. See Teratogen Exposure (includes Occupational Exposures in Pregnancy and Herbal Teratogens)
  3. Prenatal Vitamins with 400 ug Folic Acid (600 Dietary Folate Equivalents or DFE) and 150 mcg Iodine
    1. See Folic Acid dosing for high risk populations
    2. See Iodine for pregnancy recommendations
    3. Start Folic Acid 1-3 months before pregnancy and continue for at least 12 weeks postconception
    4. High dose Folic Acid (4-5 mg daily) is indicated in women at high risk for Neural Tube Defect (e.g. Epilepsy)
  4. Assess Vitamin Deficiency or overuse
    1. Avoid Vitamin A in excess of 3000 IU per day
    2. Avoid Vitamin D in excess of 400 IU per day
    3. Ensure well balanced diet
    4. Assess for Iron Deficiency
  5. Avoid Herbals which are related to Miscarriage
    1. See Herbal Teratogens
  6. Avoid excessive foods with increased risk
    1. See Nutrition in Pregnancy
    2. See Mercury Content in Fish

VI. Management: Preimplantation Genetic Diagnosis

  1. Indicated for single gene disorder risks
  2. Protocol
    1. Isolate single blastomere from Embryo at day 3
    2. Developing Embryo tested for single gene disorders
    3. Normal Embryos then implanted

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